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An independent licensee of the Blue Cross and Blue Shield Association. U7430a, 2/11
Mastering the basics to
prepare for the future
Professional Services Session
+ Credentialing and Enrollment
+ Case Management
+ Claims Overview
+ HIPAA 5010
+ Resources
+ Discussion
Topics for today
2
Credentialing and Enrollment
3
+ BCBSNC credentials all practitioners of care, ancillary
and facility providers applying for membership in the
network(s) and re-credentials the applicable contracted
practitioner, ancillary and facility providers every three
years.
+ Guidelines are followed for all managed care
practitioners, ancillary providers, and facilities applying
for participation in a managed care network. These
guidelines have been adopted by BCBSNC and adhere
to the guidelines established by the National Committee
for Quality Assurance (NCQA) and the North Carolina
Department of Insurance (NCDOI).
Credentialing
+ BCBSNC working with the Council for Affordable Quality
Healthcare (CAQH), is committed to streamlining the
administrative process for physicians and other health care
providers. ▪ BCBSNC has been an active participant in CAQH's efforts to help
eliminate the need for physicians and other health care providers to fill out and submit multiple credentialing/recredentialing applications.
+ The benefits of this innovative credentialing system:▪ Easy online or fax submission of information.
▪ Providers can easily update their information anytime and will be asked quarterly to verify the accuracy of the information on file.
▪ BCBSNC can access the credentialing information anytime as long as the provider has authorized it.
▪ BCBSNC continues to conduct data verification and review and makes an independent decision about whether a provider meets our standards for participation.
Credentialing Made Easier
+ It is a provider’s contractual obligation to ensure
BCBSNC has the most current demographic
information on file. Addresses and phone numbers are
published in directories, on the BCBSNC Web site, as
well as, the Blue Card and FEP Web sites.
+ This information is made available to members and
allows them to locate and schedule appointments with
participating providers. Accurate mailing addresses
ensure claim payments and any other type of
correspondence are received by the appropriate
recipient. Enrolling your NPI allows you to submit
claims on behalf of your patients.
Enrollment for Individual/Group Providers
+ Copy of NC License and most current renewal (if
applicable)
+ Completed W-9 Form
+ Name
+ Degree
+ Specialty
+ National Provider Identifier
+ DEA #
+ License #, Date, original signature
+ Appointment Phone Number
+ Site Address
+ Billing Address
Enrollment Applications Must Include
7
+ NPI registration is necessary to file claims for services
provided to BCBSNC members.
+ To receive payments made to the provider’s office,
providers must have an NPI number, must be
credentialed and have a contract with BCBSNC. If a
provider does not have a contract with BCBSNC,
payments are made to the subscriber.
+ NPI numbers can be registered for individuals or for a
group.
Provider NPI Registration
8
+ Statement of Supervision forms must be completed
during the credentialing process; this allows the
provider to file claims under their supervising physician.
+ This form documents that the non-participating
practitioner will be temporarily supervised by a similarly
licensed and BCBSNC credentialed practitioner for all
services provided to BCBSNC managed care members
(HMO, POS, and PPO).
+ For additional information regarding the Statement of
Supervision process, please contact a member of the
Network Management Specialist team at 800-777-
1643.
Statement of Supervision
9
Are your demographics correct? Do you need
to update your address or the providers in
your practice?
The Practice Manager
and/or Physician may
download this form and e-
mail to directly BCBSNC
at
Provider.AddressUpdates
@bcbsnc.com or fax the
form to BCBSNC at 919-
287-8884.
Network Management Specialists
+ Your Network Management Specialists are able to
assist with:
▪ Obtaining copies of your fee schedule (if you are unable to retrieve via Blue E).
▪ Making any necessary demographic changes – notice address, billing address, and etc.
▪ Add/Remove providers from your practice.
▪ Questions
Case Management
Mastering the Basics
Case Management - An Advocate for Your
Patient’s Health
CASE MANAGER
Ensures Patients Understand
• Health status
• Treatment options and
implications
• Importance of treatment
• Available resources
• Information to share with
health care professionals
Patient reaches health
goals more efficiently
and effectively…
More effective
self-management
Avoidance of health-
related complications
and care expenses
Improved health status
Member
Turning Complex Health Issues into Health
OpportunitiesGuide Patient on Impacting
Their Overall Medical and
Psychosocial SituationComprehensive
Member
Assessment
Individualized Plan
Health Needs
Health Goals
Health Resources
Nurses
Dietitians
Pharmacist
Behavioral Health
Customer Service
Complex Health Issues
High Consumer of
Service
Gaps in Care
Case Management
Opportunities
Care Givers
CASE MANAGER
ACTIONABLE
IMPACTFUL
Targeting and guiding members to
improved self-management of their
health.
Social Workers
Physician/PCMH*
* Patient Centered Medical Home
Social Workers
Medical Home Collaboration
• BCBSNC’s Care Management and
Medical Home (MH) Collaboration
Program ensures effective
communications with physicians and
improved health outcomes through
increased case management
engagement.
• Case Managers become an
extension of the physician practice
focusing on member’s health and
care gap closure and providing
ongoing, consistent communication.
Decreased medical
expense
Decrease in utilization
Increase in appropriate
utilization
Case Management and
Blue Medicare Members
+ Patients that have:
▪ History of ER visits, hospitalizations and re-admissions for chronic conditions (e.g. CVA, CAD, fibromyalgia).
▪ New diagnosis of, or poorly controlled CHF, COPD, diabetes.
▪ Lack of knowledge regarding health condition and how to self-manage.
▪ Presence of multiple co-morbidities that complicate the primary chronic condition.
▪ Social isolation or other barriers, making it difficult for the patient to follow the physician’s recommended treatment plan.
Claims Overview
+ Total 2010 Claim Volume: 42.2 Million
▪ Total Electronic Claim Volume: 38.8 million – 96%▪ Total Paper Claim Volume: 3.4 million – 4%
+ 87% Claims Processed within 7 Days:
+ Mailbacks:▪ 7% CMS-1500 Claims▪ 10% UB04 Claims
+ Provider Payments:▪ 52% are EFT payments representing 85% of monies paid▪ 48% of paper checks representing15% of monies paid
BCBSNC 2010 Claim Statistics:
19
+ Top Denials for Claims:▪ Duplicate Denials
▪ Multiple Procedures
▪ Claims Outside Member Effective Date
▪ Other Insurance Primary
▪ No Authorizations
+ Adjusted Claim Reasons:▪ Corrected Claims
▪ Medicare COB Adjustments
▪ Benefit Package Changes / Incorrect Benefit Package Applied
▪ Commercial COB Adjustments
BCBSNC 2010 Claims Experience
20
The Basics of Claims Filing
21
Professional & Facility claims
must be submitted within 180
days of services being
rendered or the date of
discharge, with the exception
of claims for State and FEP
members.
Claims for FEP members must
be filed by December 31 of the
year after services were
rendered or date of discharge.
Claims for State PPO
members must be submitted
within 18-months of services
being rendered or the date of
discharge.
Claims Timely Filing Guidelines
+ BCBSNC encourages all hospitals, physicians and
health care professionals to submit claims
electronically.
+ Electronic claims filing allows faster, more efficient and
cost-effective claim submission for hospitals, physicians
and health care professionals.
+ The benefits of filing electronically include:▪ Reduction of overhead and administrative costs
▪ Receipt of reports are proof of claim receipt
▪ Faster transaction time for claims submitted electronically
▪ Validation of data elements on the claim
▪ Quicker claim completion
Electronic Claims Submission
23
+ Member ID Number Errors▪ Professional: 32,801 claims were rejected representing $12.1
million in billed charges.
▪ Institutional: 2,963 claims were rejected representing $10.4 million in billed charges.
+ Security Errors – providers not set-up to submit claims
electronically or through a specific clearinghouse▪ Professional: 1,836 claims were rejected representing $1.2
million in billed charges.
▪ Institutional: 35 claims were rejected representing $183 thousand in billed charges.
+ Rendering NPI Errors - the rendering (performing)
physician’s NPI is not registered with BCBSNC –
professional only▪ Professional: 3,635 claims were rejected representing $1.2
million in billed charges.
Electronic Rejections – Week At A Glance
24
Duplicate and Corrected Claims
25
Duplicate Claims1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
2011 2010 2011 2010 2011 2010 2011 2010
Total
Duplicates 81,847 68,382 96,903 80,337 - 65,171 - 68,864
Total Claims 881,325 865,955 940,491 901,102 - 853,605 - 872,157
Duplicates as
% of Claims 9.29% 7.90% 10.30% 8.92% - 7.63% - 7.90%
10.9% 10.6% 10.4%9.4% 9.7% 9.8%
10.6%11.2%
11.8%
16.0%
22.2%21.2%
11.7%
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11
Duplicate Submission Rate by Month: Percent of Duplicates
+ A duplicate claim is any claim submitted by a
provider for the same service and same charge
amount provided to a particular individual on a
specified date of service that was included in a
previously submitted claim.
+ If you do not receive a response from your original
claim submission, please utilize available resources
prior to submitting a duplicate claim.
Duplicate Claim
+ Duplicate Claim Impacts:
▪ Processing Delays
– Additional Investigative Steps
▪ Unnecessary Denials
▪ Member Confusion
– Multiple EOBs
▪ Administrative Costs
– Member calls
– Resources required to research denials.
– Cost associated with resubmission.
+ A corrected claim is any claim that you have received an
NOP/EOP and need to make corrections from the original
submission.
+ Please remember the corrected claim replaces the original
claim; you must submit all charges that were on the original
claim rather than just the charge that has changed.
+ Providers using electronic data interchange (EDI) can submit
“institutional” corrected claims electronically rather than via
paper to BCBSNC.
+ Providers have 3-years from adjudication date to file a
corrected claim.
Corrected Claims
Additional Updates for Claims
30
+ Medicare Advantage claims fax line (336-659-2962) is
being removed from service on August 15, 2011.
+ New claims should be submitted electronically or via
mail to the appropriate address listed in the Provider
eManual.
+ Corrected claims should be submitted electronically
(utilizing the appropriate bill type and frequency code
per filing guidelines) or via mail.
+ Provider inquiries should be submitted by mail to
BCBSNC, PO Box 17509, Winston Salem, NC 27116-
7509.
Medicare Advantage Claims Fax Line
Removed from Service
+ BCBSNC has enhanced claims processing logic to ensure
claims process with the appropriate number of units
submitted in the “Units of Service” claim field – claim field
24G.
+ Keep in mind the following when reporting Units of Service:
Units reported are based on the Current Procedural
Terminology (CPT) code description
Field 24G is most commonly used for units of supplies,
anesthesia units, etc.
Anesthesia units should be (1) unit equals a 1-minute
increment. Note: Do not include base units of the
procedure with the time units
Reporting “Units of Service” on the
CMS-1500 claim form
32
+ BCBSNC has modified its billing and claims
submission policies and reimbursement policies and
have added a new medical policy effective 10/1/2011
that reduces the allowed amount for the technical
component of certain outpatient (hospital or provider
office) radiology procedures when performed in the
same session.
+ This updated medical policy is available at:
https://www.bcbsnc.com/assets/services/public/pdfs/
medicalpolicy/radiology_services_reimbursement_gui
delines_notification.pdf.
Multiple Radiology Procedure Payment
Reduction
Claims Filing Tips
34
+ Be sure to include patient’s correct alpha prefix.▪ FEP starts with an “R”
+ Claims should be typed and not hand-written.
+ Please do not highlight data on a claim, EOB, and any
other documentation that is submitted.
+ Ensure all required and conditional data elements are
populated on the UB04 claims form.
+ Use the most current and appropriate CPT and ICD-9
codes, when submitting claims to BCBSNC.
Claims Filing Tips
+ Allow sufficient time for Medicare primary claims to
crossover from Medicare.
+ Verify and submit all COB information.
+ Avoid filing new claims as corrected claims.
+ Avoid submitting paper claims.
+ Ensure your NPI numbers are register and linked
appropriately.
+ Submit requested medical records timely.
Tips to help prevent claim processing delays
HIPAA 5010
Mastering the Basics
+ An ERRATA (addenda) was approved at the end of
2010 that defined new versions for the 270/271, 837I,
837P, and 835 transactions.
+ Our 5010 migration updates and revised time lines:
5010 Trading Partner Migration
Transaction BCBSNC Migration Timeline
270/271 Eligibility Inquiry/Response July – December
276/277 Claim Status Inquiry/Response August – December
278 Authorization Request/Response July (late) – December
837 Institutional Claim Submission Sept – December
837 Professional Claim Submission Sept – December
835 Electronic Remittance Advice July (late) - December
999 Acknowledgement July through 2011
+ Complete the Migration Request Form ▪ www.bcbsnc.com/content/providers/edi/hipaainfo/agreements.htm
+ eSolutions analyst contacts trading partner
+ Test each transaction type in test environment
+ After passing compliance testing, eSolutions migrates the
vendor to 5010 versions
+ Note: ▪ BCBSNC will accept both 4010 and 5010 versions of all transactions
for the remainder of 2011.
▪ Once a vendor migrates to the 5010 version of 835, the 4010 is no longer sent.
▪ As of October 1st, no requests for 4010 set-ups will be accepted..
Migrating to Version 5010: Process for
Trading Partners
39
Resources
40
+ Members believed to have
other coverage should be
given a copy of the COB
questionnaire for completion.▪ Once completed, the member will
mail it to their Home Plan
+ This form is available for
download at:
http://www.bcbsnc.com/assets
/common/pdfs/BCBSNCCOBq
uestion.pdf.
IPP Coordination of Benefits Form
Follow the State Health Plan on
Spanish speaking patients
Web site:
www.bcbsnc.com/azul/
Spanish-speaking customer service
1-877-258-3334
Are you interested in
attending an in-depth
Provider Training
session?
If so, contact your
Provider Relations
Representative for details
on attending a session
located near you!
We’re serious about health care reform. Here’s how to make it work.
Available on the Web
Online resources –
bcbsnc.com/providers/
Blue e
Discussion
Best Practices
49
Thank you!
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